coronary involvement in takayasu’s arteritis
DESCRIPTION
Coronary Involvement in Takayasu’s Arteritis. Saori Kobayashi. University of Tokyo Hospital. wards. clinical lab OR. clinics. Takayasu’s Arteritis(TA). Vasculitis of aorta and its primary branch →stenosis and aneurysm Japan, Southeast Asia, India, and Mexico Male:Female=1:9, - PowerPoint PPT PresentationTRANSCRIPT
Coronary Involvement in Takayasu’s Arteritis
Saori Kobayashi
University of Tokyo Hospital
clinics
clinical lab OR
wards
Takayasu’s Arteritis(TA)
Vasculitis of aorta and its primary branch →stenosis and aneurysm
Japan, Southeast Asia, India, and Mexico Male:Female=1:9, Most common in their 20’s~30’s
May involve coronary artery
→dyspnea, palpitations, angina, MI, CHF
TA and Atherosclerosis chronic inflammatio
n cause atherosclerosis
Higher incidence than the other collagen disease
↑sensitivity of platelets to collagen, ↑thromboxane B2
cause thrombosis
0
5
10
15
20
25
30
TA SLE normal
Incidence of arteriosclerosis in carotid artery(Seyahi et al.)
Coronary involvement in TA
Occurs in 10 ~ 30% Often fatal Classified into 3 pathorogic types
Type1:stenosis or occlusion of coronary ostia
Type2:diffuse or focal coronary arteritis
Type3:coronary aneurism
2/3!
Treatment of TA
・
Steroids(>6mo remission:28%)
immunosuppressant :Cyclosporin,Cyclophosphamide,Methotrexate,etc..
Anti-platelet therapy( low-dose Aspirin)
angioplasty/surgery
If uncontrolled
Control of vasculitis
Symptomatic occulusion
thrombosis
Treatment for coronary artery occulusion in TAsurgery ( CABG,MIDCAB) ・・ often not indicated
・ because internal thoracic artery can’t be used due to occulusion of braciocepharic a./sabclavian a.
・ because of calcification of aorta
High incidence of restenosis:36 %angioplasty(PTCA)
・ alternative to surgery
Often lead to unsatisfactory results
Very high incidence of restenosis:78 %
Recent stent : DES
DES(drug-eluting stent):
・ elute drug such as Paclitaxel or Siloromus
・ expected to inhibit proliferation of vascular endotherium and prevent restenosis and thrombosis
・ Actually 、 has dramatic effect to prevent restenosis.
Applying DES to TA Case:53yo female Diagnosed with TA when Pt is 42yo, had been treate
d with Prednisone Angina of effort at the age of 53 、 90 % stenosis at
LCA ostia was detected. Refused surgery and PTCA was performed (bare-m
etal stent)→0%stenosis 、 asymptomatic Angina relapsed 3 mo after 、 90 % restenosis wa
s detected → PTCA(Sirolimus-Eluting Stent)6 mo after 、 asymptomatic and no stenosis was dete
cted
Applying DES to TA
There are many cases reported that DES is effective in patients who had bare-metal PTCA and had recurrent restenosis
There is no evidence that DES improve the prognosis of TA more than bare-metal stent
How do DES work in ordinary atherosclerosis ?
DES in ordinary atherosclerosis:BASKET-LATE Trial 746 patients randomly assigned to DES group or BMS gr
oup(n=499, 244, respectively) Taking clopidogrel for 6mo→without clopidogel for 12mo
DES BMSRestenosis-related target vascular revascularization
4.5% 6.7%
Primary endpoint ( cardiac death, non-fatal MI after discontinuation of clopidogrel )
4.9% 1.3%
Thrombosis-rerated events 2.6% 1.3%
DES in normal arteriosclerosis
DES
Prevention of restenosis(8.7%→4.9%)
↑incidence of cardiac event by thrombosis→need to take anti-platelet agent
Do we really need to use DES?
BMS in TA
Extremely high incidence of restenosis;78%
( 5%/18mo in usual arteriosclerosis) Recurrent in several months:↓QOL, ADL Surgical therapy is often not indicated Progression of atherosclerois/restenosis h
as correlation with inflammation activity
DES in TA
DES may contribute as a “bridge” until inflammation control is obtained
DES
Suppress neointimal hyperplasia +attenuate arteritis
→lower risk of restenosis→QOL improvement
↑cardiac event?
Conclusion Coronary lesion in TA occurs most often in o
stia High incidence of restenosis If bare-metal ste
nt is applied Given unique character of atherosclerosis in
TA, selective use of DES limited to patients with an uncontrolled inflammation may contribute to improve patency rates of future definite interventions v(^_^)v
References
Moche Rav-Acha et al. Coronary involvement in Takayasu’s arteritis Autoimmunity Reviews 6 2007;566-571
Furukawa Y et al, Sirolimus-Eluting Stent for In-Stent Restenosis of Left Main Coronary Artery in Takayasu Arteritis Circ J 2005;69:752-755
Matthias Pfistereer et al. Late Clinical events After Clopidogrel Discintinuation May Limit the Benefit of Drug –Eruting Stents. The Lancet 2007; 370:1552-1559
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